graph TD
A[Pediatric macular hole dx between Jan 2013 - Oct 2024 <br> 3098 eyes, 2763 patients]
A --> B[Exclusions due to concomitant dx: <br> 348 eyes, 258 patients<br>Loss to F/U: 1217 eyes, 1101 patients<br> Unspecified eye: 145 eyes, 145 patients<br> Missing demographic data : 704 eyes, 636 patients ]
B --> C[Remaining: 684 eyes, 623 patients]
C --> D[Surgery group: 129 eyes, 129 patients]
C --> E[Observation group: 555 eyes, 494 patients]
D --> F[Surgical Complications: 24 patients]
E --> G[Surgical Complications: 22 patients]
Outcomes of Pediatric Macular Hole
BPEI Biostatistics Center
Hypothesis: Macular hole surgery for pediatric macular hole has favorable visual outcomes and a low rate of complications. However, patients managed with observation may also have favorable visual outcomes.
Rationale: Pediatric macular holes are less common than adult macular holes and usually are discovered in the setting of trauma. Though some pediatric macular holes may close with observation alone, others may require surgery. As this is a rare condition, clinical natural course and history studies are limited. The purpose of this study is to explore the clinical outcomes associated with pediatric macular hole in a large dataset.
Data extraction
Summary
Variable | Overall | Observation | Surgery | p-value2 |
|---|---|---|---|---|
Sex | 0.3 | |||
Female | 219 (35%) | 179 (36%) | 40 (31%) | |
Male | 404 (65%) | 315 (64%) | 89 (69%) | |
Both eyes included | 61 (9.8%) | 58 (12%) | 3 (2.3%) | 0.001 |
Age at first macular hole diagnosis | 14.00 (11.00, 16.00) | 14.00 (11.00, 16.00) | 14.00 (11.00, 15.00) | 0.8 |
Age at macular hole diagnosis for fellow eye | 13.00 (9.00, 16.00) | 13.00 (9.00, 16.00) | 13.00 (11.00, 16.00) | 0.7 |
Unknown | 562 | 436 | 126 | |
Race | 0.5 | |||
Asian | 20 (3.2%) | 18 (3.6%) | 2 (1.6%) | |
Black Or African American | 99 (16%) | 74 (15%) | 25 (19%) | |
Other | 108 (17%) | 87 (18%) | 21 (16%) | |
White | 396 (64%) | 315 (64%) | 81 (63%) | |
Ethnicity | 0.3 | |||
Hispanic Or Latino | 105 (17%) | 79 (16%) | 26 (20%) | |
Not Hispanic Or Latino | 518 (83%) | 415 (84%) | 103 (80%) | |
Region | >0.9 | |||
Midwest | 143 (23%) | 111 (22%) | 32 (25%) | |
Northeast | 122 (20%) | 98 (20%) | 24 (19%) | |
South | 267 (43%) | 214 (43%) | 53 (41%) | |
West | 91 (15%) | 71 (14%) | 20 (16%) | |
Follow up (months) | 35.45 (15.44, 64.16) | 38.58 (16.62, 67.64) | 24.38 (13.50, 47.14) | <0.001 |
Note: Three patients are count in both groups as they had one eye in each group | ||||
1n (%); Median (Q1, Q3) | ||||
2Pearson's Chi-squared test; Wilcoxon rank sum test; Fisher's exact test | ||||
Observation group
Variable | No surgical complication | Complex RD | Photocoagulation | Scleral buckling | Vitrectomy | p-value2 |
|---|---|---|---|---|---|---|
Sex | 0.8 | |||||
Female | 170 (36%) | 4 (36%) | 3 (38%) | 1 (100%) | 1 (50%) | |
Male | 305 (64%) | 7 (64%) | 5 (63%) | 0 (0%) | 1 (50%) | |
Both eyes included | 54 (11%) | 0 (0%) | 3 (38%) | 1 (100%) | 0 (0%) | 0.025 |
Bilateral surgery | 0 (NA%) | 0 (0%) | 2 (25%) | 1 (100%) | 0 (0%) | 0.056 |
Unknown | 475 | 0 | 0 | 0 | 0 | |
Age at first macular hole diagnosis | 14.00 (11.00, 16.00) | 14.00 (12.00, 16.00) | 11.00 (10.00, 14.50) | 17.00 (17.00, 17.00) | 14.00 (11.00, 17.00) | 0.4 |
Age at macular hole diagnosis for fellow eye | 13.00 (9.00, 16.00) | NA (NA, NA) | 13.00 (10.00, 17.00) | 17.00 (17.00, 17.00) | NA (NA, NA) | 0.3 |
Unknown | 421 | 11 | 5 | 0 | 2 | |
Time to complication (days) | NA (NA, NA) | 34.00 (16.00, 893.00) | 30.00 (10.00, 1,463.00) | 303.00 (303.00, 303.00) | 217.00 (22.00, 412.00) | >0.9 |
Unknown | 475 | 0 | 1 | 0 | 0 | |
Time to complication, fellow eye(days) | NA (NA, NA) | NA (NA, NA) | 702.00 (623.00, 1,161.00) | 681.00 (681.00, 681.00) | NA (NA, NA) | 0.7 |
Unknown | 475 | 11 | 5 | 0 | 2 | |
Race | 0.038 | |||||
Asian | 16 (3.4%) | 0 (0%) | 2 (25%) | 0 (0%) | 0 (0%) | |
Black Or African American | 70 (15%) | 3 (27%) | 1 (13%) | 0 (0%) | 0 (0%) | |
Other | 82 (17%) | 5 (45%) | 2 (25%) | 0 (0%) | 0 (0%) | |
White | 307 (65%) | 3 (27%) | 3 (38%) | 1 (100%) | 2 (100%) | |
Ethnicity | 0.2 | |||||
Hispanic Or Latino | 74 (16%) | 3 (27%) | 2 (25%) | 1 (100%) | 0 (0%) | |
Not Hispanic Or Latino | 401 (84%) | 8 (73%) | 6 (75%) | 0 (0%) | 2 (100%) | |
Region | 0.9 | |||||
Midwest | 108 (23%) | 2 (18%) | 1 (13%) | 0 (0%) | 0 (0%) | |
Northeast | 97 (20%) | 1 (9.1%) | 2 (25%) | 0 (0%) | 0 (0%) | |
South | 202 (43%) | 5 (45%) | 5 (63%) | 1 (100%) | 2 (100%) | |
West | 68 (14%) | 3 (27%) | 0 (0%) | 0 (0%) | 0 (0%) | |
Follow up (months) | 37.42 (16.20, 66.69) | 56.31 (35.97, 87.75) | 72.62 (37.17, 88.26) | 58.05 (58.05, 58.05) | 72.60 (34.79, 110.41) | 0.2 |
1n (%); Median (Q1, Q3) | ||||||
2Fisher's exact test; Kruskal-Wallis rank sum test | ||||||
Surgical group
Variable | No surgical complication | Cataract Surgery | Macular Hole Surgery | Retinal Detachment Surgery | p-value2 |
|---|---|---|---|---|---|
Sex | 0.5 | ||||
Female | 32 (30%) | 2 (33%) | 6 (43%) | 0 (0%) | |
Male | 73 (70%) | 4 (67%) | 8 (57%) | 4 (100%) | |
Age at first macular hole diagnosis | 14.00 (11.00, 15.00) | 16.00 (15.00, 17.00) | 10.50 (7.00, 13.00) | 12.50 (11.50, 13.50) | 0.005 |
Time to complication (days) | NA (NA, NA) | 532.00 (268.00, 725.00) | 69.00 (21.00, 147.00) | 38.00 (20.00, 73.00) | 0.001 |
Unknown | 105 | 0 | 0 | 0 | |
Race | 0.4 | ||||
Asian | 1 (1.0%) | 0 (0%) | 0 (0%) | 1 (25%) | |
Black Or African American | 20 (19%) | 1 (17%) | 4 (29%) | 0 (0%) | |
Other | 18 (17%) | 1 (17%) | 2 (14%) | 0 (0%) | |
White | 66 (63%) | 4 (67%) | 8 (57%) | 3 (75%) | |
Ethnicity | 0.2 | ||||
Hispanic Or Latino | 19 (18%) | 2 (33%) | 3 (21%) | 2 (50%) | |
Not Hispanic Or Latino | 86 (82%) | 4 (67%) | 11 (79%) | 2 (50%) | |
Region | 0.9 | ||||
Midwest | 25 (24%) | 2 (33%) | 4 (29%) | 1 (25%) | |
Northeast | 20 (19%) | 0 (0%) | 2 (14%) | 2 (50%) | |
South | 44 (42%) | 3 (50%) | 5 (36%) | 1 (25%) | |
West | 16 (15%) | 1 (17%) | 3 (21%) | 0 (0%) | |
Follow up (months) | 23.46 (13.34, 46.12) | 27.45 (19.05, 49.74) | 43.64 (11.27, 74.74) | 16.06 (12.12, 23.55) | 0.5 |
Note: No one from the surgical group had a Endophthalmitis diagnosis. | |||||
1n (%); Median (Q1, Q3) | |||||
2Fisher's exact test; Kruskal-Wallis rank sum test | |||||
VA comparison
These results suggest that while surgical patients started with worse VA, both groups experienced comparable gains in vision over time.
Category | Key Findings |
|---|---|
Baseline Difference | - Surgical patients had 48% worse VA at baseline compared to the observed group (Exp(β) = 1.48, p < 0.001). |
Time Effects | - Both groups showed significant improvement at all follow-up timepoints (p < 0.01) |
Variable | Multiplicative Effect | p-value | ||
|---|---|---|---|---|
Variable | Exp(β) | 95% CI (Lower) | 95% CI (Upper) | p-value |
(Intercept) | 0.7944374 | 0.7350682 | 0.8586016 | <0.001 |
group_typeSurgical | 1.4773713 | 1.2746061 | 1.7123925 | <0.001 |
timepoint3MO | 0.7976433 | 0.7383788 | 0.8616646 | <0.001 |
timepoint6MO | 0.7523988 | 0.6874750 | 0.8234538 | <0.001 |
timepoint1Y | 0.7860029 | 0.7221201 | 0.8555372 | <0.001 |
timepoint2Y | 0.8157669 | 0.7274438 | 0.9148138 | <0.001 |
GEE Forest plot
Time to max BCVA
Logistic Mixed Effects Model
Variable | Overall | Observation | Surgery | p-value2 |
|---|---|---|---|---|
Age at macular hole diagnosis | 14 (11, 16) | 14 (11, 16) | 14 (11, 16) | 0.9 |
Sex | 0.2 | |||
Female | 214 (36%) | 178 (37%) | 36 (31%) | |
Male | 379 (64%) | 300 (63%) | 79 (69%) | |
Race | 0.4 | |||
Black Or African American | 100 (17%) | 76 (16%) | 24 (21%) | |
Other | 121 (20%) | 100 (21%) | 21 (18%) | |
White | 372 (63%) | 302 (63%) | 70 (61%) | |
Ethnicity | 0.5 | |||
Hispanic Or Latino | 95 (16%) | 74 (15%) | 21 (18%) | |
Not Hispanic Or Latino | 498 (84%) | 404 (85%) | 94 (82%) | |
Region | 0.5 | |||
Midwest | 135 (23%) | 103 (22%) | 32 (28%) | |
Northeast | 126 (21%) | 103 (22%) | 23 (20%) | |
South | 246 (41%) | 200 (42%) | 46 (40%) | |
West | 86 (15%) | 72 (15%) | 14 (12%) | |
VA (logMAR) | 0.54 (0.18, 1.00) | 0.48 (0.10, 1.00) | 1.00 (0.54, 1.18) | <0.001 |
VA groups | <0.001 | |||
Normal | 204 (34%) | 195 (41%) | 9 (7.8%) | |
Mild | 128 (22%) | 100 (21%) | 28 (24%) | |
Moderate | 138 (23%) | 93 (19%) | 45 (39%) | |
Severe | 123 (21%) | 90 (19%) | 33 (29%) | |
1Median (Q1, Q3); n (%) | ||||
2Wilcoxon rank sum test; Pearson's Chi-squared test | ||||
Vision impairment (as classified by the vision_group variable) is a strong predictor of surgery, with those in the “Mild,” “Moderate,” and “Severe” vision groups having much higher odds of surgery compared to those with “Normal” vision. The severity of vision impairment increases the odds of surgery.
Other variables such as age, sex, and ethnicity do not significantly predict whether a patient has surgery.
Overall, these results provide evidence that patients with worse vision are more likely to undergo surgery, supporting the notion that visual acuity at baseline plays a crucial role in surgical decisions.
| Univariate Models | Multivariate Model | ||||
|---|---|---|---|---|---|---|
Univariate Analysis | OR | 95% CI | p-value | OR | 95% CI | p-value |
ageatdx | 1.01 | 0.76, 1.36 | 0.926 | 1.02 | 0.95, 1.10 | 0.554 |
sex | ||||||
Female | — | — | — | — | ||
Male | 1.30 | 0.16, 10.8 | 0.807 | 1.17 | 0.70, 1.93 | 0.552 |
race | ||||||
Black Or African American | — | — | — | — | ||
Other | 0.60 | 0.02, 14.8 | 0.753 | 0.57 | 0.25, 1.33 | 0.194 |
White | 0.70 | 0.06, 8.55 | 0.781 | 0.65 | 0.34, 1.25 | 0.193 |
ethnicity | ||||||
Hispanic Or Latino | — | — | — | — | ||
Not Hispanic Or Latino | 0.81 | 0.06, 10.8 | 0.874 | 0.58 | 0.29, 1.18 | 0.133 |
region | ||||||
Midwest | — | — | — | — | ||
Northeast | 0.66 | 0.04, 12.4 | 0.784 | 0.77 | 0.38, 1.57 | 0.477 |
South | 0.71 | 0.06, 8.09 | 0.786 | 0.64 | 0.34, 1.21 | 0.169 |
West | 0.60 | 0.02, 17.2 | 0.767 | 0.54 | 0.23, 1.25 | 0.149 |
vision_group | ||||||
Normal | — | — | — | — | ||
Mild | 6.52 | 2.76, 15.4 | <0.001 | 7.33 | 3.01, 17.8 | <0.001 |
Moderate | 11.7 | 4.76, 29.0 | <0.001 | 12.2 | 4.77, 31.2 | <0.001 |
Severe | 8.69 | 3.62, 20.9 | <0.001 | 8.68 | 3.53, 21.3 | <0.001 |
Abbreviations: CI = Confidence Interval, OR = Odds Ratio | ||||||